Specialist Rehabilitation Services Research Articles

Paediatric neurorehabilitation: finding and filling the gaps through the use of the Institute for Manufacturing strategic roadmapping method

IntroductionAcquired brain injury (ABI) is a major cause of morbidity and mortality in childhood. Specialist rehabilitation services are often situated far from families and local services may be non-standardised and...

Rehabilitation in momentum of Norwegian coordination reform: From practices of discipline to disciplinary practices

The way rehabilitation is given meaning and practiced relies on contesting assumptions, affecting the conception of who will benefit from rehabilitation and the way professionals define their relationship with patients. This article applies a critical discourse analysis of interviews with rehabilitation professionals, investigating the way they talk about rehabilitation, and the ways their language use produces utterances, concepts, and affects their practices. The context of the analysis is time of change imposed by Norwegian health reform policies targeted towards efficiency and decreased public health cost. A meta-discourse of goals is identified, in which four further discourses are singled out; rehabilitation as catalyst for a meaningful living; rehabilitation as professional performance; rehabilitation as constraint factor, and rehabilitation as a normative stimulus for independence. The article concludes that rehabilitation professionals include policy-informed rationing in clinical reasoning processes. The consequence is that institutional rehabilitation practices depart from patient-centered, socially invented schemes of care. Rehabilitation professionals act as powerful agents on behalf of the authorities, approaching the disabled and chronically ill in ways to make them independent and self-managing with less involvement of specialized rehabilitation services.

Rehabilitation Needs of Refugees with Disabilities in the United States: Implications for Vocational Rehabilitation Counselors

The global instability caused by natural and human-made disasters has resulted in increased numbers of refugees who seek shelter in other countries. The United States admits refugees and provides services that enable these refugees to resettle in a new environment. Among these refugees are individuals with various disabilities who require specialized rehabilitation services. This paper reviews the challenges faced by refugees with disabilities before, during and after their resettlement in the US and explores how counselors can better serve this population in order to facilitate more effective and timely integration into American society. Implications for research and practice are discussed.

Transitions of patients with traumatic brain injury and multiple trauma between specialized and municipal rehabilitation services—Professionals’ perspectives

AbstractRehabilitation is a complex field requiring broad interprofessional and interorganizational collaboration. System-induced setbacks, such as rehospitalization and decreased quality of care, can occur when patients transition between services. The focus of this study is the rehabilitation of patients experiencing traumatic brain injury (TBI) and multiple trauma. The aim of the study was to explore rehabilitation professionals’ perspectives on interprofessional collaboration and coordination during transitions of patients with TBI and multiple trauma between specialized and municipal rehabilitation services. The study used a qualitative design based on a grounded theory approach. Data were collected at two specialized rehabilitation units through observation of interprofessional meetings and 16 semi-structured individual interviews with participating professionals. Eight focus group discussions were also conducted with professionals at the municipal rehabilitation services. Data were recorded, transc...

Understanding community-based rehabilitation and the role of physical and rehabilitation medicine.

Community-based rehabilitation (CBR) is an accepted model to improve the delivery of rehabilitation in the community. It includes the access to health care, education, labor and accessible environments. The role of Specialists in Physical and Rehabilitation Medicine in this strategy (SPRM) is not very well defined. On the occasion of the international consultation for the WHO Action Plan for persons with disabilities, a discussion about the meaning of CBR and the role of SPRM on CBR has occurred among the International Society of Physical and Rehabilitation Medicine (ISPRM) members. The following major questions were identified; what is CBR? What is the role of Specialists in Physical and Rehabilitation Medicine (SPMR) in CBR? A review of the literature and a discussion among experts was held to answer these questions. It is of major importance to distinguish between the two concepts of CBR: The first one is the policy or management strategy of CBR that was developed by WHO about 30 years ago. The second one is the provision of basic rehabilitation services offered at the community level. CBR strategy must also addresses the need for optimal access to specialized rehabilitation services and will have a key role in the design and building of so-called "Basic Rehabilitation Services." The authors proposed a scheme, which integrates all relevant aspects surrounding the concept of CBR; levels of care rehabilitation services and the roles proposed for SPRM. In addition, the convention for the rights of persons with disabilities and the conceptual framework of the ICF was taken into account.

Early outcomes of the implementation of physiotherapist independent prescribing in a specialist rehabilitation service for persons with lower limb amputation

Early outcomes of the implementation of physiotherapist independent prescribing in a specialist rehabilitation service for persons with lower limb amputation

Neurorehabilitation: applied neuroplasticity

The prevalence of disability due to neurological conditions is escalating worldwide. Neurological disorders have significant disability-burden with long-term functional and psychosocial issues, requiring specialized rehabilitation services for comprehensive management, especially treatments tapping into brain recovery 'neuroplastic' processes. Neurorehabilitation is interdisciplinary and cross-sectorial, requiring coordinated effort of diverse sectors, professions, patients and community to manage complex condition-related disability. This review provides evidence for a range of neurorehabilitation interventions for four common neurological conditions: multiple sclerosis (MS), stroke, traumatic brain injury and Parkinson's disease using the Grade of Recommendation, Assessment, Development and Evaluation tool for quality of evidence. Although, existing best-evidence for many interventions is still sparse, the overall findings suggest 'strong' evidence for physical therapy and psychological intervention for improved patient outcomes; and. 'moderate' evidence for multidisciplinary rehabilitation for longer term gains at the levels of activity (disability) and participation in MS and stroke population. The effect of other rehabilitation interventions is inconclusive, due to a paucity of methodologically robust studies. More research is needed to improve evidence-base for many promising rehabilitation interventions.

Hospital discharge of patients with disabling neurological injury: necessary referrals to rehabilitation.

The present qualitative study was conducted in the second semester of 2014 via interviews with 12 doctors and 13 nurses working as managers at a large hospital that serves as a reference center for urgent and emergent care in the Zona da Mata region of Minas Gerais State, Brazil. The study sought to identify the criteria that doctors and nurses use to discharge individuals with disabling neurological injury with instructions related to accessing physical rehabilitation programs. Thematic content analysis was used to examine data. The results show that the participating hospital managers still have difficulties providing adequate referrals to specialized rehabilitation services and that their patients' autonomy and independence for self-care are impaired as a result. We concluded that in addition to involving relatives and other caregivers in the discharge of patients with a neurological injury that impairs their self-care abilities, managers should assess the accessibility of the patient's home and make adequate referrals to rehabilitation services in the community in light of the poor dispersal of information about what is available within the Care for People with Disability Network.

Cost-efficiency of specialist hyperacute in-patient rehabilitation services for medically unstable patients with complex rehabilitation needs: a prospective cohort analysis

ObjectivesTo evaluate functional outcomes, care needs and cost-efficiency of hyperacute (HA) rehabilitation for a cohort of in-patients with complex neurological disability and unstable medical/surgical conditions.DesignA multicentre cohort analysis of prospectively...

The effects of the Norwegian Coordination Reform on the use of rehabilitation services: panel data analyses of service use, 2010 to 2013.

BackgroundIn 2012 the Norwegian Coordination Reform was implemented. The main motivation was to encourage municipalities to expand local, primary health care services. From 2012 to 2014, under the Municipal Co-Financing regime, municipalities were obliged to cover 20 % of the costs of health services provided at the specialist (hospital) level. Importantly, use of rehabilitation services in private institutions was not part of the cost-sharing mechanism of Municipal Co-Financing. Rehabilitation services may be seen as quite similar in nature whether they be provided by municipalities, hospitals or private institutions. Thus, with rehabilitation patients readily “transferrable” between levels, the question is whether the reform brought with it a sought after shift towards more municipal rehabilitation and less specialist rehabilitation.MethodsData from the Norwegian Patient Register and from Statistics Norway/KOSTRA were utilized to gauge annual expenditures and inputs in specialist, municipal and private institution rehabilitation services respectively. Fixed effects and first difference regression analyses for the period 2010–2013 were carried out to account for certain time-invariant traits of municipalities and/or hospital regions, and results were adjusted for contemporaneous trends in local needs.ResultsExpenditures in specialist rehabilitation services declined sharply (typically by 8–10 %) from 2011 (pre-reform) to 2012 (post-reform), while expenditures in private rehabilitation services rose markedly in the same period (typically by 42–44 %). The results do not suggest any general expansion of municipal rehabilitation services.ConclusionsThe results of the analyses suggest that municipalities shift away from the use of specialist rehabilitation services and towards the use of rehabilitation services in private institutions since the latter becomes relatively cheaper (free-of charge) than both municipal and specialist services in post-reform periods (as specialist services come at a cost to municipalities post-reform). While the main goal of the reform has not materialized the results nevertheless suggest that incentives (of cost-shifting) do play a significant role in rehabilitation service use.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1564-6) contains supplementary material, which is available to authorized users.

Cost-efficiency of specialist inpatient rehabilitation for working-aged adults with complex neurological disabilities: a multicentre cohort analysis of a national clinical data set

ObjectivesTo evaluate functional outcomes, care needs and cost-efficiency of specialist rehabilitation for a multicentre cohort of inpatients with complex neurological disability, comparing different diagnostic groups across 3 levels of dependency.DesignA...

Experiences of pathways, outcomes and choice after severe traumatic brain injury under no-fault versus fault-based motor accident insurance

Primary objective: To explore experiences of pathways, outcomes and choice after motor vehicle accident (MVA) acquired severe traumatic brain injury (sTBI) under fault-based vs no-fault motor accident insurance (MAI).Methods: In-depth qualitative interviews with 10 adults with sTBI and 17 family members examined experiences of pathways, outcomes and choice and how these were shaped by both compensable status and interactions with service providers and service funders under a no-fault and a fault-based MAI scheme. Participants were sampled to provide variation in compensable status, injury severity, time post-injury and metropolitan vs regional residency. Interviews were recorded, transcribed and thematically analysed to identify dominant themes under each scheme.Results: Dominant themes emerging under the no-fault scheme included: (a) rehabilitation-focused pathways; (b) a sense of security; and (c) bounded choices. Dominant themes under the fault-based scheme included: (a) resource-rationed pathways; (b) pressured lives; and (c) unknown choices. Participants under the no-fault scheme experienced superior access to specialist rehabilitation services, greater surety of support and more choice over how rehabilitation and life-time care needs were met.Conclusions: This study provides valuable insights into individual experiences under fault-based vs no-fault MAI. Implications for an injury insurance scheme design to optimize pathways, outcomes and choice after sTBI are discussed.

Major Burn Trauma Management and Nursing Care

Major burn injury is one of the most serious and often life-threatening forms of trauma. Burn patients not only suffer from the physical, psychological, social and spiritual impacts of their injury but also experience considerable changes in health-related quality of life. This paper presents a review of the literature on the implications of previous research and clinical care guidelines related to major burn injuries in order to help clinical practice nurses use evidence-based care guidelines to respond to initial injury assessments, better manage the complex systemic response to these injuries, and provide specialist wound care, emotional support, and rehabilitation services.

Expanding stroke telerehabilitation services to rural veterans: a qualitative study on patient experiences using the robotic stroke therapy delivery and monitoring system program

Purpose: The present study reports on a robotic stroke therapy delivery and monitoring system intervention. The aims of this pilot implementation project were to determine participants' general impressions about the benefits and barriers of using robotic therapy devices for in-home rehabilitation. Methods: We used a qualitative study design employing ethnographic-based anthropological methods including direct observation of the in-home environment and in-depth semi-structured interviews with 10 users of the hand or foot robotic devices. Thematic analysis was conducted using an inductive approach. Results: Participants reported positive experiences with the robotic stroke therapy delivery and monitoring system. Benefits included convenience, self-reported increased mobility, improved mood and an outlet for physical and mental tension and anxiety. Barriers to use were few and included difficulties with placing the device on the body, bulkiness of the monitor and modem connection problems. Conclusions: Telerehabilitation robotic devices can be used as a tool to extend effective, evidence-based and specialized rehabilitation services for upper and lower limb rehabilitation to rural Veterans with poor access to care. Implications for Rehabilitation Participants whose formal therapy services had ended either because they had exhausted their benefits or because traveling to outpatient therapy was too cumbersome due to distance were able to perform therapeutic activities in the home daily (or at least multiple times per week). Participants who were still receiving formal therapy services either in-home or in the clinic were able to perform therapeutic activities in the home on the days they were not attending/receiving formal therapy. Based on the feedback from these veterans and their caregivers, the manufacturing company is working on modifying the devices to be less cumbersome and more user-friendly (lighter-weight, more mobile, changing software, etc.), as well as more adaptable to participants' homes. Removing these specific barriers will potentially allow participants to utilize the device more easily and more frequently. Since participants expressed that they wished they could have the device in their homes longer than the 3-month usage period required for this pilot project, the project team is working on a proposal to extend this project to a wider area and the new paradigm would extend the usage period until the patient reaches a plateau in progress or no longer wants to use the device.

Strategies for implementing a regional cross continuum care pathway to improve outcomes for patients with hip fracture in Ontario, Canada

Background: Hip fracture is a serious, potentially life altering event for older adults. Without rapid access to surgery and specialized rehabilitation services, many patients never regain pre-fracture levels of independent living. The Bone and Joint Canada National Hip Fracture Toolkit (2011) and Ontario's Quality Based Procedures Clinical Handbook for Hip Fracture (2013) outline evidence-based approaches to drive better patient experience, outcomes and cost. Kotter (1996) described an 8-step model to facilitate successful change management on an organizational or system level.

Clinicians experience of using a digital media tool in rehabilitation services to help patients communicate the nature of pain and body perception disturbances

Introduction: People with persistent pain often have altered perceptions of parts of their body. For example they can perceive their affected limbs as having some distortions of size, perhaps with enlarged hands or very thin forearms. They can also feel that areas of body or limb segments are much colder or hotter than they really are. These experiences can be difficult for people to communicate to clinicians. Service users have requested to have a tool that portrays their pain experience in a more visual and in-depth manner than standard methods using drawings or numerical rating scales. A digital media tool developed by the research team gives users an on-screen image of a 3D human figure which can be manipulated to give an impression of their body perception. They can resize and reposition any body parts that they feel are different and apply textures to represent perceived sensations such as burning, cold, hard ‘stone like’ feelings, or the feeling of body parts being insubstantial. The tool was initially evaluated with a sample of 13 participants with Complex Regional Pain Syndrome (CRPS)1. The participants liked using the tool. The quality of the graphics enhanced the reality of the image thereby helping them to convey how altered their bodies seem to them. Aims: The tool is now being implemented in rehabilitation services at the Royal National Hospital for Rheumatic Diseases, Bath. The aim is to evaluate benefits of using the tool to the rehabilitation services from the clinician’s perspective. Methods: The application is being routinely used in two specialist rehabilitation services with two different long term conditions: 1. CRPS, 2. Breast radiation injury post cancer. Patients use the tool in consultation with an Occupational Therapist. The Occupational Therapist demonstrates the International Digital Health and Care Congress, The King’s Fund, London, September 10-12 2014. International Journal of Integrated Care – Volume 14, 01 November – URN:NBN:NL:UI:10-1-116525– http://www.ijic.org/ options on the application and operates the software in response to instructions from the patient to achieve a representation that is to their specification. After a bedding in period of at least six weeks in each service, the views of clinicians about using the tool will be collected in semi-structured interviews. The data will be analysed to determine the effects of using the body perception tool on service provision and changes needed to the software or its implementation. Results: Work in progress

Service stakeholders' perspectives on methadone maintenance treatment, Special Community Employment schemes and client recovery pathways

BACKGROUND: Previous Irish research on client perspectives on the ‘lived social world’ of methadone maintenance treatment (MMT) and participation in Special Community Employment (SCE) schemes have illustrated how MMT offers clients the opportunity to commence recovery and community reintegration, with participation in the SCE schemes acting primarily as therapeutic support mechanism with improvement needed in work based support and employment related outcomes. OBJECTIVES: The research aimed to explore service providers’ views on MMT client experiences of participation in SCE vocational training, education and employment seeking. METHODS: Five in depth interviews and three focus groups (n = 14) were conducted with key specialist treatment and rehabilitation service providers’ in Dublin, Ireland. RESULTS: Narratives were thematically analysed, and indicative of the positive role of MMT in recovery pathways in terms of stimulating initial client stabilisation, reducing client chaotic lifestyles, initiating new positive health and social behaviours with partners, children, families, and facilitating renewed vocational training on SCE schemes. Outcomes whilst positive in terms of personal development when in recovery are compromised by lack of employment prospects and dedicated work-based supports on exit. CONCLUSIONS: Recommendations were made around the need for long term integrated community care, vocational certification, supported volunteer, employment planning and back to work schemes.

A Mobile Rehabilitation Clinic to Extend Specialized Services to Community-Based Outreach Clinics

To determine the feasibility and satisfaction with a Mobile Rehabilitation Clinic (MRC) for delivery of specialized rehabilitation services in rural areas to increase patient access to care by minimizing patient driving distance. Case series Mobile Rehabilitation Clinic (MRC) travelling to CBOCs to deliver care closer to patient residences. Thus far, 141 patients (97% male, age=76.4±11.3 years) have received gait and fall risk assessments and/or been issued mobility device(s) in this MRC at three CBOCs. The majority of patients were referred to the MRC due to a history of falls or for being at high risk for falls. Most patients had five or more comorbidities and received at least one prosthetic item during their visit (walker, cane, and/or home safety equipment). N/A Patient driving miles saved by MRU care delivery model and patient satisfaction with services. MRC patients have needed to drive an average of 62 miles less to MRC appointments than they would have driven to reach the main hospital. 86% of patients rated their satisfaction with services received as excellent. Patients and caregivers said that they were previously unable to benefit from these services due to the distance required to travel to the main hospital to receive them. This MRC model is an effective method of improving access to care in vulnerable older adults that live far from hospitals capable of providing specialized care.

Initial psychometric evaluation of the Arm Activity Measure (ArmA): a measure of activity in the hemiparetic arm

Objective: To evaluate the psychometric properties of the Arm Activity Measure (ArmA), a patient-reported measure of active and passive function in the paretic upper limb. Design: Psychometric evaluation study. Setting: Two specialist rehabilitation and spasticity management services. Method: Patients (n = 92) with upper limb paresis were recruited from two specialist neurorehabilitation centres. Mean age 44.5 (SD 16.7). Diagnostic distribution: stroke 48 (52%); other brain injury 28 (31%); or other neurological condition 16 (17%). Evaluation of convergent and divergent validity; unidimensionality, scaling, reliability (internal consistency and test–retest); responsiveness to change and feasibility of the ArmA were undertaken. Results: Expected convergent and divergent relationships were seen with the Leeds Adult Spasticity Impact Scale and the Disabilities of Arm Shoulder and Hand (DASH) (rho 0.5–0.63). Principal components analysis confirmed that active and passive function formed two separate constructs in each sub-scale. Mokken analysis corroborated the findings of the principal components analysis and demonstrated scaling using the monotone homogeneity model (Item H>0.5 for all items). Cronbach’s alpha was 0.85 and 0.96, respectively, for the passive and active function subscales. Item level test–retest agreement ranged from 92-97.5% (quadratic-weighted Kappa 0.71-0.94). In the subgroup treated for spasticity with botulinum toxin (n = 58), the ArmA passive function scale identified a significant difference between responder and non-responder groups (Mann Whitney U = 0.85, p < 0.01). Respondents reported the ArmA to be relevant (77%), easy to use (90%) and timely to complete (83% under 10 minutes). Conclusion: The ArmA is a valid and reliable tool feasible for use in the evaluation of upper limb function in the context of treatment for spasticity.

Costs of caring for adults with long-term neurological conditions

To estimate and compare the costs of informal and formal care provided to adults with long term neurological conditions and to identify characteristics associated with these costs. Cross-sectional postal questionnaire survey. Family carers of 282 adults with sudden onset, progressive and stable/intermittent conditions were recruited through UK-wide voluntary organisations and neuroscience centres. Carers provided demographic and condition specific information about the adults cared for. Informal care was measured with the Caregiver Activity Survey and formal service use with the Client Service Receipt Inventory. Costs were calculated and regression analyses identified demographic and clinical characteristics associated with cost. Annual informal care costs mean £82,620 (standard deviation 58,493) were 4 times higher than formal costs mean £18,117 (standard deviation 28,990). Caring for adults with sudden onset conditions and hidden/mixed impairments were both significantly associated with informal costs. Healthcare costs were significantly associated with having a sudden onset condition, greater dependency in activities of daily living and longer condition duration. Greater dependency was significantly associated with increased social care costs. The cost of caring for adults with long term neurological conditions is largely borne by families. Both health and social costs are higher for more dependent patients, endorsing the importance of developing specialist rehabilitation services that reduce dependency.